S21C257 - Trauma to the Neck Flashcards
Zones
Zone I: clavicles to cricoid cartilage
-includes vertebral and proximal carotid arteries, major thoracis vessels, superior mediastinum, lungs, esophagus, trachea, thoracic duct and spinal cord
Zone II: inferior margin of cricoid cartilage to the angle fo the mandible
-contains carotid, vertebral arteries, jugular veins, esophagus, trachea, larynx, spinal cord
Zone III: b/w angle of mandible and base of skull
-contains distal carotid and vertebral arteries, pharynx, spinal cord
Anatomy of neck
- platysma - most superficial structure beneath skin and subcutaneous tissue
- if the platysma is violated immediate surgical consultation is necessary
- do not probe neck wounds beneath the platysma
ABC management of neck trauma
- intubate early before distortion occurs
- cricothyroidotomy may be required
- with ETT intubation, be careful not to complete a partial transection
- clinical factors that indicate aggressive airway management: resp distress, airway obstruction from blood/secretions, massive subcu emphysema, tracheal shift, altered mental status, expanding hematoma
-check neuro status b/c risk of SCI from direct injury or ischemia
Hard signs of Neck injury
- hypotension
- active arterial bleeding
- diminished carotid pulse
- expanding hematoma
- thrill/ruit
-lateralizing signs
- hemothorax (>1000cc)
- air or bubbling wound
- hemoptysis
- hematemsis
- tracheal deviation
Soft Signs of Neck injury
- hypotension in the filed
- hx of arterial beeding
- unexplained bradycardia (w/o CNS injury)
- nonexpanding large hematoma
- apical capping on CXR
- stridor
- hoarseness
- vocal cord parlysis
- subcu emphysema
- 7th cranial nerve injury
Penetrating neck injury: dx and mgmt
-if unstable or obvious aerodigestive injury –> immediate surgery
Zone I: lungs, trachea, esoph, spine, vertebral/carotid a., thoracic vessels
-CXR to detect pneumo/hemothorax
Zone II: carotid/vertebral a., IJ/EJ v., spine, larynx, trachea
-imaging or exploratory surgery
Zone III: distal carotid/vertebral a., pharynx, spine
-evaluation by selective, nonoperative mgmt, no routine exploration
-CT angio is the initial diagnostic test, NPV 100%, sensitivty 98.6% for arterial lesions, more limited in zone I and III
Esophageal injuris
- complications: neck space infxns and mediastinitis
- investigate with CT
- other workup: contrast esophagography, scope
Laryngotracheal injury
- Zone I and II
- signs: anterior/superficial position of trachea, air bubbling through wound, dsyspnea, stridor, hemoptysis, subcu emphysema
- investigations: CT
Children and penetrating neck trauma
-observation may be ok for asymptomatic pts with zone II penetrating injuries
Blunt Trauma to Neck
- injuries: edema, hematoma, lacerations, vocal cord avulsion, # of thyroid and cricoid cartilage, recurrent laryngeal nerve laceration, complete laryngotracheal disruption
- practice varies b/w ETT intubation or tracheostomy, cricothyroidotomy should be avoided b/c this may worsen laryngeal injury
- carotid injury: hematoma, bruit, ipsilateral Horner syndrome, TIA, contralateral motor/sensory deficit
- vertebral artery injury: can occur with chiropractic manipulation, Sx vary from neck pain to Wallenberg syndrome or stroke
- Tx: if blunt cervical vascular injury present, give anticoagulation to reduce risk of stroke, if AC contraindicated, give antiplatelet tx
Wallenberg syndrome
- AKA: lateral medullary infarction syndrome
- ipsilateral facial loss of pain and temperature, isolated loss of cranial nerves V, IX, X, XI, cerebellar ataxia, horner syndrome, contralateral loss of pain/temp
- locked in syndrome
- quadriplegia
Strangulation
- hanging, ligature strangulation, manual strangulation, postural strangulation
- death from strangulation occcurs from spinal cord damage or brainstem injury, constriction of neck structures, or bradycardic cardiac arrest
- complete = feet dangling
- incompelte = everything else
